case report modified surgical techniques for managing intraoperative floppy iris...

Case ReportModified Surgical Techniques for Managing IntraoperativeFloppy Iris Syndrome

Pornchai Simaroj,1 Kaevalin Lekhanont,1 and Puwat Charukamnoetkanok2

1Department of Ophthalmology, Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand2Department of Ophthalmology, Mettapracharak (Wat Rai Khing) Hospital, Nakhon Pathom, Thailand

Correspondence should be addressed to Pornchai Simaroj; [email protected]

Received 4 July 2016; Revised 29 September 2016; Accepted 7 November 2016

Academic Editor: Vishal Jhanji

Copyright © 2016 Pornchai Simaroj et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Purpose. To report a modified surgical strategy in the management of intraoperative floppy iris syndrome-associated iris prolapse.Methods. Prolapsed iris is left as is and a new corneal incision near the original wound but at a different site is created. Dependingon the location of the original incision and the surgeon’s preference, this additional incision can be used as a new port forphacoemulsification tip or can be the new site for the iris to securely prolapse, allowing for the surgery to proceed safely. Results.Wepresent 2 cases of iris prolapse and inadequate pupil dilation in patientswith IFIS. Alongwith ourmodified technique, additional irisretractors were placed to increase the workspace for the phacoemulsification tip. The cataract surgery was performed successfullywithout further complications in both cases.Conclusion.This surgical technique could be an adjunct to allow the surgeons to expandthe armamentarium for the management of IFIS-associated iris prolapse.

1. Introduction

Intraoperative floppy iris syndrome (IFIS) was first describedin 2005 by Chang and Campbell as a triad of intraoperativesigns: (a) billowing of a flaccid iris stroma, (b) a propensityfor iris to prolapse toward the phaco- and site-port incisions,and (c) progressive intraoperative pupil constriction [1]. IFISis classified as severe (when all 3 features are present), mod-erate (billowing and intraoperative miosis), and mild (irisbillowing only) [1]. Systemic alpha-1 antagonists associatedIFIS, especially tamsulosin, were reported [2]. Chang andCampbell also postulated that systemic tamsulosin blockedcontraction of the smooth muscle of iris dilator that reducedmuscle tone causing poor pupil dilation, iris floppiness, anda propensity to prolapse [1]. Several procedures to managethe iris problems in IFIS have been proposed includingthe use of highly viscous or viscoadaptive ophthalmic vis-cosurgical devices (OVDs) in conjunction with low-flowsurgical techniques, the use of bimanual microincision pha-coemulsification, and the placement of iris retractors [3].Intracameral injection of alpha-agonist drugs (phenylephrineor adrenaline) has also been shown to be effective for

preventing IFIS [4, 5]. Although some advocated the use ofpreoperative topical atropine to maximize cycloplegia in eyesat risk for IFIS, additional intracameral phenylephrine or irisretractors might be required [3]. The purpose of this study isto report a modified surgical strategy in the management ofIFIS-associated iris prolapse, besides medications.

2. Materials and Methods

Our technique is similar to Tint’s. Tint et al. used a single stabincision posterior to phacoemulsificationwound, and a singleiris retractor was placed [6]. However, if the original incisionis too close to the limbus, it will be difficult to do a second stabincision posterior to it. Our technique leaves prolapsed irisas is and creates a new incision near the original wound butat a different site. Depending on the location of the originalincision and the surgeon’s preference, this additional incisioncan be used as a new port for phacoemulsification tip or canbe the new site for the iris to securely prolapse allowing for thesurgery to proceed safely (Figure 1). Additional iris retractorscan be used as necessary.

Hindawi Publishing CorporationCase Reports in Ophthalmological MedicineVolume 2016, Article ID 1289834, 4 pageshttp://dx.doi.org/10.1155/2016/1289834

2 Case Reports in Ophthalmological Medicine

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

(j)

Figure 1: Photographs demonstrating our surgical technique to manage IFIS. In Patient 1, the iris prolapsed during hydrodissection andhydrodelineation (a). Prolapsed iris was left incarcerated in the first incision. Two iris retractors were placed to ensure adequate pupil sizeand the second main incision was made at 12 o’clock (b). Phacoemulsification was continued via the new superior incision (c). Prolapsed iristissue was repositioned with OVDS after IOL implantation and OVDS removal (d). In Patient 2, during hydrodissection, the iris prolapsedthrough themain incision, similar to Patient 1 (e).The secondmain incisionwas created lateral to the original incision (f). Phacoemulsificationwas attempted via the new incision but the pupil started to constrict (g). Phacoemulsification was then performed via the original mainwound instead, leaving the iris prolapsed through the second main wound. Nonetheless, the pupil was getting more constricted (h). Threeiris retractors were placed and the surgery was continued without further complications (i). Each main wound was sutured at the completionof surgery (j).

Case Reports in Ophthalmological Medicine 3

2.1. Surgical Techniques

2.1.1. Case 1. A 62-year-old-man was evaluated for cataractsurgery. The medical history included hypertension, hyper-lipidemia, and benign prostatic hypertrophy. Medicationswere amlodipine, simvastatin, and tamsulosin. Slit-lampexamination revealed bilateral nuclear sclerotic cataracts,clear corneas, deep anterior chambers, and unremarkablefundoscopy. His best correct visual acuity was 6/24 in botheyes. After giving informed consent, phacoemulsificationwas performed in the left eye under peribulbar anesthesia.The pupil was moderately dilated. A superotemporal inci-sion and a single side-port incision were done. Followinghydrodissection, the iris prolapsed through themain incisionand the pupil constricted (Figure 1(a)). Prolapsed iris wasleft in place. Two iris retractors were placed to ensureadequate pupil size and the second main incision was madeat 12 o’clock (Figure 1(b)). Phacoemulsification was donevia superior incision (Figure 1(c)). Because of the surgeonpreference, Simcoe’s needle was used for cortex removaland an intraocular lens (IOL) was implanted under OVDs.Iris retractors and OVDs were removed. Prolapsed iris wasrepositioned with OVDs and BSS (Figure 1(d)). Stromalhydration was performed gently. Four weeks postoperatively,the examination revealed minimal anterior iris tissue loss butno transillumination defect and the refraction was −0.50–1.0× 90 with the BCVA of 6/6.

2.1.2. Case 2. A 77-year-old man presented with decreasingvision in the right eye. He had cataract surgery in his left eye5 years ago. The medical history included hypertension andprostatic carcinoma after radiotherapy for 2 years. Medica-tions included amlodipine and alfuzosin (Xatral XL�). Hisbest corrected visual acuity (BCVA) was 6/24 in the right eyeand 6/6 in the left eye. Cornea and anterior chamber depthwere within normal parameters. Nuclear sclerotic cataractwas found in the right eye and IOL was found in the left eye.Dilated fundoscopy was unremarkable.

After obtaining informed consent, the patient underwentphacoemulsification with peribulbar anesthesia in the righteye by a third-year resident under supervision of the author(PS). The pupil was well dilated preoperatively. A temporalclear cornea incision and a single side-port incision wereconstructed. Continuous curvilinear capsulorhexis (CCC)was performed underOVDs.During hydrodissection, the irisprolapsed through the main incision (Figure 1(e)). A secondmain incision was made inferior to the first one (8 o’clock)(Figure 1(f)). Phacoemulsification was tried via the secondmain wound but the pupil constricted slowly (Figure 1(g)).We decided to switch the surgeon. The prolapsed iris wasrepositioned with OVDs and phacoemulsification was con-tinued via the original main wound (Figure 1(h)). After inser-tion of the phacoemulsification tip, the iris prolapsed throughthe new incision and the pupil constricted further. Thephacoemulsification tip was removed and three iris retractorswere placed (Figure 1(i)).The surgery was completed withoutfurther complications. Prolapsed iris was repositioned withOVDs. Each wound was secured using a single 10-0 nylon

suture (Figure 1(j)). The residual OVDs were removed byneedle irrigation and aspiration.

3. Discussion

IFIS is not an uncommon intraoperative complication andis often associated with the use of adrenergic antagonistssuch as tamsulosin. The overall prevalence is 1.5–2.5%, andthe incidence of IFIS in patients treated with systemicalpha-1 antagonists ranges from 40 to more than 80% [7].Iris prolapse can occur suddenly following hydrodissectionparticularly in cases of posterior limbal incision. Traumato iris can occur during the manipulation to reposition theprolapsed iris causing iris tissue loss, bleeding (hyphema),infection, inflammation, postoperative iris transilluminationdefects, or monocular diplopia. Furthermore, IFIS may causereduction of the pupil size that adds difficulty to the surgery.

Generally, certain basic surgical principles such as carefulconstruction of appropriately sized incisions, the use of verygentle hydrodissection, lowering the irrigation inflow rateif possible, and directing irrigation currents away from thepupillary margin should be universally applied to preventIFIS [3]. Numerous approaches including pharmacologicagents, the use of highly viscous or viscoadaptive OVDs,and placement of mechanical dilating devices have beenemployed to manage the iris in IFIS [3]. Intracameraladrenaline or phenylephrine usage appeared to be effectivein preventing intraoperative miosis or the floppy iris syn-drome seen in patients who are on the drug tamsulosin forbenign prostatic hypertrophy, during cataract surgery [4, 5].Positioning iris retractors in a diamond configuration hasalso been recommended because the retractors maximizeexposure immediately in front of the phacoemulsificationtip and pull the iris posteriorly away from it [3]. Tint et al.suggested placement of a single stab incision posterior tophacoemulsification wound with one iris retractor under themain incision [6]. However, this techniquemay be difficult incases where the original incision is too close to the limbus.

Our technique is primarily aimed at naturally convertingthe crisis of iris prolapse into instrument-free iris retractor. Anew main incision was placed at the most suitable position.Additional iris retractors were used when the pupil wassmall or constricted during the surgery. With these methods,the surgeon was able to continue and safely finished theoperation. At the end of surgery, the trapped iris wasgently freed and repositioned with OVDs and the woundwas secured with minimal stromal hydration or cornealsuture. This technique minimizes the trauma to the iris andreduces the chance of other intraoperative complications.Nonetheless, because of the wide range of IFIS severity, eachdifferent technique may be appropriate for each individual.Furthermore, using combination or multiple techniques maybe needed if a single method alone was not sufficiently safe.Therefore, this surgical technique could be an adjunct toallow the surgeons to expand the armamentarium for themanagement of IFIS-associated iris prolapse.

4 Case Reports in Ophthalmological Medicine

4. Conclusions

Creation of an additional clear corneal incision as a new pha-coemulsification wound could be a useful surgical strategyin the management of IFIS-associated iris prolapse duringphacoemulsification cataract surgery.

Competing Interests

The authors declare that they have no competing interests.

References

[1] D. F. Chang and J. R. Campbell, “Intraoperative floppy irissyndrome associated with tamsulosin,” Journal of Cataract andRefractive Surgery, vol. 31, no. 4, pp. 664–673, 2005.

[2] T. Oshika, Y. Ohashi, M. Inamura et al., “Incidence of intra-operative floppy iris syndrome in patients on either systemicor topical 𝛼1-adrenoceptor antagonist,” American Journal ofOphthalmology, vol. 143, no. 1, pp. 150–151, 2007.

[3] D. F. Chang, R. H.Osher, L.Wang, andD.D. Koch, “Prospectivemulticenter evaluation of cataract surgery in patients takingtamsulosin (Flomax),” Ophthalmology, vol. 114, no. 5, pp. 957–964, 2007.

[4] T. Takmaz and I. Can, “Clinical features, complications andincidence of intraoperative floppy iris syndrome associatedwithtamsulosin,” European Journal of Ophthalmology, vol. 17, pp.909–913, 2007.

[5] A. Gurbaxani and R. Packard, “Intracameral phenylephrine toprevent floppy iris syndrome during cataract surgery in patientson tamsulosin,” Eye, vol. 21, no. 3, pp. 331–332, 2007.

[6] N. L. Tint, A. M. Yeung, and P. Alexander, “Managementof intraoperative floppy-iris syndrome-associated iris prolapseusing a single iris retractor,” Journal of Cataract and RefractiveSurgery, vol. 35, no. 11, pp. 1849–1852, 2009.

[7] A. Storr-Paulsen, J. S. Jørgensen, J. C. Norregaard, and J. Thule-sen, “Corneal endothelial cell changes after cataract surgery inpatients on systemic sympathetic 𝛼-1a antagonist medication(tamsulosin),”ActaOphthalmologica, vol. 92, no. 4, pp. 359–363,2014.

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